A multimodal initiative improves general pediatric provider management of atopic dermatitis in children: A prospective interventional study
Authors: Stephanie S. Lee, Anshika Kaushik, Nicola Natsis, Ayan Kusari, David Schairer, Sarah Lindback, Mark Levenberg, J. Rebecca Mills, Kathleen Peeples, Richard Smith, Lawrence F. Eichenfield
Journal: Journal of the American Academy of Dermatology (2023)

Atopic dermatitis (AD) is common in children, and pediatricians are often the first health care practitioners to provide evaluation and treatment.1Eichenfield L.F. Boguniewicz M. Simpson E.L. et al.Translating atopic dermatitis management guidelines into practice for primary care providers.Pediatrics. 2015; 136: 554-565https://doi.org/10.1542/peds.2014-3678Google Scholar Limited training, fear of steroids, and lack of specific volumetric prescriptions for topical medications can contribute to suboptimal treatment of AD in the primary care setting. We sought to improve and standardize AD care by pediatric providers with a multimodal intervention comprising education and electronic health record (EHR)-integrated tools that assist with prescription writing and generating customized care plans. At Rady Children's Hospital-San Diego, pediatric AD specialists collaborated with a large pediatric primary care group to design and execute this prospective, interventional study. For AD education, pediatricians participated in a live training session led by a pediatric dermatologist, and patient materials were developed and distributed. In the EHR, a topical medication volume calculator (TMVC) for streamlined personalized volumetric prescriptions was implemented. The TMVC is based on a cubic regression model,2Natsis N. Kusari A. Han A. Kaushik A. Eichenfield L. Patient perceptions of the quantity of topical corticosteroids advised for the treatment of atopic dermatitis: an evidence-based rationale for future solutions in aiding patient-provider communication in atopic dermatitis management.J Am Acad Dermatol. 2019; 81: AB252https://doi.org/10.1016/j.jaad.2019.06.1115Google Scholar, 3Nelson A.A. Miller A.D. Fleischer A.B. Balkrishnan R. Feldman S.R. How much of a topical agent should be prescribed for children of different sizes?.J Dermatolog Treat. 2006; 17: 224-228https://doi.org/10.1080/09546630600894998Google Scholar, 4Long C.C. Finlay A.Y. The finger-tip unit--a new practical measure.Clin Exp Dermatol. 1991; 16: 444-447https://doi.org/10.1111/j.1365-2230.1991.tb01232.xGoogle Scholar which estimates the volume of topical medications, in grams, to be used over a several-week period based on patient age and body surface area involvement (Fig 1). AD on the head was excluded for simplification. An AD order set was built for streamlined selection of therapeutic regimens (Supplementary Fig 1, available via Mendeley at https://data.mendeley.com/datasets/7sc9yc2j6p/1). After an appropriate treatment is selected in the order set and 2 data points are entered in the TMVC (age and body surface area), prescriptions are available for electronic processing, with personalized volumetric prescription directions and AD materials generated for patients/caretakers (Supplementary Fig 2, available via Mendeley at https://data. mendeley.com/datasets/7sc9yc2j6p/1). Educational reinforcement for providers was accomplished through a 20-minute podcast and a pediatrician-led video demonstrating the use of the TMVC and AD order set. To assess the interventions' impact on pediatric providers' knowledge and management of AD, a survey for providers and EHR data extraction at baseline and 1-year postintervention were employed. Based on the survey results (81 respondents at baseline and 38 postintervention), there was improvement in reported provider comfort with understanding and diagnosis of AD along with prescriptions of topical and systemic medications for AD (Table I). The average number of case-based questions answered correctly increased from 76% before intervention to 82% after intervention (P =.012). EHR data documented use of the AD order set and TMVC during the time of the study intervention. Although the number of AD-related visits was similar, pediatricians prescribed more topical corticosteroids for AD postintervention (Supplementary Fig 3, available via Mendeley at https://data.mendeley.com/datasets/7sc9yc2j6p/1), which may be an indication of reduced steroid phobia.Table IParticipant comfort level with atopic dermatitis–related topics before and after intervention on a 5-point scale∗1 indicates "poor" and 5 indicates "excellent."1, n (%)2, n (%)3, n (%)4, n (%)5, n (%)Mean (SD)P value†Determined using Student t test.Understanding of pathophysiology and epidemiology Before intervention (N = 80)0 (0)2 (2.5)30 (37.5)37 (46.3)11 (13.8)3.7 (0.7).022 After intervention (N = 38)0 (0)0 (0)6 (15.8)26 (68.4)6 (15.8)4.0 (0.6)Diagnosing atopic dermatitis Before intervention (N = 79)0 (0)0 (0)6 (7.6)49 (62.0)24 (30.4)4.2 (0.6).202 After intervention (N = 38)0 (0)0 (0)1 (2.6)22 (57.9)15 (39.5)4.4 (0.5)Prescribing topical therapies for atopic dermatitis Before intervention (N = 80)0 (0)0 (0)15 (18.8)49 (61.3)16 (20.0)4.0 (0.6).008 After intervention (N = 38)0 (0)0 (0)0 (0)27 (71.1)11 (28.9)4.3 (0.5)Prescribing systemic therapies for atopic dermatitis Before intervention (N = 79)23 (29.1)27 (34.2)17 (21.5)11 (13.9)1 (1.3)2.2 (1.1).008 After intervention (N = 38)5 (13.2)9 (23.7)13 (34.2)10 (26.3)1 (2.6)2.8 (1.1)∗ 1 indicates "poor" and 5 indicates "excellent."† Determined using Student t test. Open table in a new tab Overall, this multimodal intervention was a successful collaboration between pediatric dermatologists and pediatricians, with demonstration of changes in care delivery for children with AD in the primary care setting. Study limitations included the single-center setting and impact of the COVID-19 pandemic, which may have affected participation in the program and postintervention survey completion. The TMVC and AD order set were integrated into a commonly utilized EHR system (Epic), and an implementation guide was created to facilitate its replication in other healthcare systems. Future studies to evaluate the utility of the TMVC on medication adherence and treatment outcomes would be useful. LFE has served as a consultant or investigator for AbbVie, Almirall, Arcutis, Arena, Dermavant, Eli Lilly and Company, Forté, Galderma, Incyte, Novartis, Ortho Dermatologics, Otsuka, Pfizer Inc., Regeneron, and Sanofi-Genzyme. ML, JRM, KP, and RS are employees and shareholders of Pfizer Inc. SSL, AK, NN, AK, DS, and SL declare no conflicts of interest.